A nurse is receiving information about four children during change-of-shift report. Which of the following children should the nurse assess first?

A 12-year-old child who has cystic fibrosis and reports difficulty clearing secretions

A 3-year-old child who has an atrial septal defect and a heart rate of 120/min

A 5-year-old child who has type 1 diabetes mellitus and a blood sugar of 150 mg/dL

A 2-year-old child who has diarrhea and reports abdominal pain

Answer and Explanation

The Correct Answer is A

A. A child with cystic fibrosis and difficulty clearing secretions is the priority because airway clearance is critical in cystic fibrosis. Mucus buildup can lead to respiratory distress and infection, requiring immediate intervention.
B. A child with an atrial septal defect and a heart rate of 120/min is not the priority because a heart rate of 120/min is within the expected range for a 3-year-old and does not indicate immediate distress.
C. A child with type 1 diabetes and a blood sugar of 150 mg/dL is not the priority because this blood glucose level is slightly elevated but not critical.
D. A child with diarrhea and abdominal pain requires assessment, but dehydration or electrolyte imbalance develops over time. Airway issues take priority over gastrointestinal symptoms.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Scant lochia rubra with a few small clots. Lochia rubra is expected in the early postpartum period, and small clots are normal unless excessive bleeding occurs.
B. Urine output 2,500 mL/day. Increased urine output is expected postpartum as the body eliminates excess fluid retained during pregnancy.
C. Bilateral ankle edema. Mild edema is common postpartum due to fluid shifts and typically resolves on its own.
D. 4+ deep-tendon reflexes. Hyperreflexia is a sign of central nervous system irritability and may indicate preeclampsia, which requires immediate evaluation.

A. "You can expect to feel some pulsations in your neck during the procedure." B. "You'll wake up about 30 minutes after the procedure." C. "You might feel a bit confused for a few hours after the procedure." D. "You might notice some changes in your voice after the procedure."

Correct Answer is C

Explanation

A. Feeling pulsations in the neck is not an expected sensation during electroconvulsive therapy (ECT). The client is under general anesthesia and does not feel the procedure.
B. The client typically wakes up within 5 to 10 minutes after ECT, though they may remain drowsy for a while. 30 minutes is too long for initial awakening.
C. Post-procedure confusion and memory loss are common and temporary side effects of ECT, lasting a few hours to days in some cases.
D. Voice changes are not associated with ECT. The procedure does not affect the vocal cords or speech.

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A nurse is receiving information about four children during change-of-shift report. Which of the following children should the nurse assess first?

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